Recently in Partner Site: Haiti Category

While Abby has been teaching ultrasound at St. Damien's, Hope, Adam, and I have been working on an evaluation project of a protocol for the admission of pediatric patients with severe acute malnutrition. Ben Trappey, who is currently a Med Peds faculty member, our faculty advisor for the rotation, and also in the department of global pediatrics, did a four-week rotation at St. Damien's during his Med Peds residency. While here, he worked with the staff to design an order set for malnutrition. The order set was based on both the World Health Organization standards for the treatment of acute malnutrition and also on the Haitian Ministry of Health protocol, and includes best practice guidelines like appropriate rehydration, feeding, and vitamin supplementation. The staff at St. Damien's, including nurses and physicians, underwent an intensive training on its use in April of this year.

One of the attendings asked us to evaluate the use of the order set. We are evaluating two outcomes: whether the order set was initiated upon admission to observation and whether the child survived to hospital discharge. This evaluation is made easier by the department of Archives at St. Damien's. All children who present with severe acute malnutrition, as defined by a weight-for-age Z-score of less than negative three or a weight-for-age Z-score of less than negative two with edema are entered into a book and this data is eventually shared with the Ministry of Health.

The Department of Archives

The Department of Archives has shared the book with us so that we can pull all of the charts from children admitted between January 1st and October 31st of this year. From the chart we gather admission weight, gender, co-morbidities, and the above two objectives. If the child did not survive to hospital discharge, we attempt to create a narrative history of the admission in addition to collecting objective data like vital signs, lab results, and blood sugar measurements, in order to understand as best as we can why the death occurred. We will be collating and analyzing this data to share with the staff of St. Damien's. Ideally together we will discover clinical correlates that could be intervened upon and then perhaps improve outcomes.

Calla Brown (MP3) at The Department of Archives

Hope Pogemiller (MP4) at The Department of Archives

This quality improvement project has been interesting on many levels. Firstly, we have seen many children who have been admitted for severe acute malnutrition, and in taking care of these children in partnership with the staff of St. Damien's, we have realized how critically ill a child with malnutrition can be. Secondly, doing the project has inspired us to learn more about how treatment protocols for malnutrition were developed and what creative methods for its treatment have been implemented in different settings. Thirdly, we have learned what a behemoth of a task it is to keep track of hundreds of thousands of paper charts in a navigable way. We are still analyzing the data but we are excited to see what comes of this project. Whatever the outcome, however, I think I can speak for all three of us when I say that we have learned a great deal.

I am fascinated by ultrasound. In medical school I had the privilege of rotating at HCMC for an ultrasound rotation through the emergency medicine department. I spent a month learning everything from bedside FAST (Focused Assessment with Sonography for Trauma) exams and the basic bedside applications to looking for retropharyngeal (behind the throat) abscesses with intra-oral probe and confirming fracture reduction in the arm. Unfortunately, keeping these skills up during residency hasn't really been a priority due to the ready availability of excellent ultrasound technicians and pediatric radiologists. But I like looking at the images my patients get and guessing the diagnoses before the official read comes back. I occasionally would page through my Pocket Atlas of Emergency Ultrasound (by one of the HCMC faculty among others) to remember how I would do the studies myself.

Then I started preparing for Haiti.

Aside from X-rays, we knew an ultrasound machine was the only available imaging within the St. Damien's. I was excited about renewing my skills and asked Ben Trappey, our MedPeds hospitalist attending coordinating our trip, if the staff at the hospital would be interested in a little handbook on bedside use of ultrasound that I could do for my academic project.

They were.

After cramping my wrist at 5 am trying to get good RUQ views with the portable ultrasound in my call room, I had enough images for my project. I put together pictures of the buttons from our machines in the ED and on the floor for a mix of the way symbols appear and reviewed some radiology literature for images of clinical pathology. I printed up the guide on Saturday before we left and Ben presented it to our Haitian contacts when we arrived.

Ultrasound machine with Abby Montague's newly created bedside use of ultrasound booklet easily accessible on the side

One of the first ultrasounds we did here was evaluating a child with TB for pleural effusion (fluid around the lung). It was so grossly abnormal at first we couldn't find our landmarks. As we kept looking, we realized we were probably seeing TB cavitations within consolidated lung tissue (holes in the lung). It was impressive. The next was a child with abdominal distention who ended up having a complex cystic mass that was so large we couldn't tell if it was coming from the liver or the left kidney (on opposite sides of the body). Kids don't come to the hospital until they are really sick and their imaging findings, whether chest xray or ultrasound, tend to be dramatically pathologic. At first, the staff just asked us to go do the ultrasounds which couldn't happen until most people were gone for the day. Gradually, they started crowding around to look at the images in real time.

One of the new residents was the first to accept the transducer. Each ultrasound, I would pass it around to see if anyone wanted to practice, receiving a lot of smiling and head shaking with French explanations I couldn't understand. The resident, Renee, was admitting a child she suspected had intussusception (intestine stuck within intestine). After explaining my lack of training with intestinal imaging again (having attempted an appendix ultrasound the first week), I asked her to just start looking since we had equal lack of experience in this case. I shamelessly endorsed my ultrasound guide and showed her the pages about the difference between the probes and the standard probe positioning. She started scanning the abdomen and found a tubular structure with a target appearance in cross section. Never having ultrasounded a child before, she recognized the characteristic finding without prompting. The staff all came around to look and we had a long discussion about the next steps. With no fluoroscopy available, the child would need to have a reduction through an open abdominal surgery. A stunningly textbook history and suggestive abdominal film would have sent the child for reduction regardless. But I can't describe how satisfying it was to watch the resident add to her own clinical suspicion using ultrasound with minimal help.

One day I was asked to ECHO a cyanotic newborn. I am comfortable with the subxyphoid view but I couldn't remember the orientation of the alternative views of looking at the heart. The very same Pocket Atlas I used in MN had made its way to Haiti prior to our arrival and and I grabbed it from the stack of English textbooks on the registration desk to re-orient myself. Renee and I talked through the chapter on cardiac imaging, each tried a couple views and came to the conclusion the right ventricle was small and we could not determine much else. But the physician I had handed the book to was now flipping through other chapters to see what was possible with this machine they've acquired and now wanders in our direction to look over our shoulders whenever we bring the ultrasound out from radiology.

I have not stopped being completely anxious about people relying on our novicely obtained images. We are asked on a daily basis to ultrasound outside of our scope of familiarity - like the ECHO's for congenital heart disease, the intestinal ultrasonography, and examinations for biliary atresia. I've only turned down one request to look for peripheral pulmonary stenosis since I don't even know how to find the pulmonary arteries. But the giant septated pleural effusions are becoming more familiar and a new staff tried her hand at visualizing one today.

I've revived an old love and maxed out the space on my flash drive bringing home images to share with Ben. But I wish I had an image of the look on Renee's face when she found the right angle to visualize the heart. I felt like I really had brought something to give. Our Haitian colleagues have been most generous in sharing knowledge, skills, and gracious acceptance. My hope is that in this small way, we've shared something worthwhile in return.

On our walk to the villa one day after a brief rain, we were startled by the beauty of 2 rainbows stretching across the sky. We all stood back by the walls of the compound next to the road and excitedly pointed at the rainbows. We shouted excitedly to a man passing by, and he smiled and taught us the name for rainbow in kreyol as he walked. Everyone from security guards to cooks to patients are pleased with attempts to learn kreyol, and it is amazing how patiently they repeat words and help us to construct phrases each day.

A double rainbow

Hope Pogemiller (MP4) and Adam Foss (MP4) at the compound

As we bid farewell to so many favorite colleagues and community contacts, we often receive a wish that our final few days be multiplied 100 fold. We are surrounded by an intense love of Haiti that is shared by so many Haitians and aid workers alike. The spirit of Haiti has crept into our souls, and even in our final days of this month we are practicing kreyol at dinner and planning our return.

Posted on behalf of Hope Pogemiller (MP4) as she tells the legend of the day Adam Foss (MP4) brought the incentive spirometer to St Luc

St. Luc hospital cares for patients 13 years and older.
Since the doctors are trained primarily in adult medicine, the style of care
delivery leans toward the adult end of the spectrum. As is often topic of
discussion in the med/peds realm, delivery of care to children and adults is
fundamentally different. This has remained constant in our observations at St.
Luc.

In the past few weeks, we have been
able to help patiently tease out history and current complaints from young
patients at St. Luc. Noting a dire need for incentive spirometry,Adam introduced bubbles today to a 15 year
old male with a severe respiratory infection that leaves him sweating in rigors
each evening and unable to sit up in bed due to generalized weakness.

Adam Foss (MP4) making incentive spirometry

His chest xray, unstable respiratory status,
and continued fevers have raised concern for tuberculosis.

He was therefore
ordered to produce an early morning sputum during rounds one morning.

He cried
out and mumbled something that was translated by staff as him refusing to
cough.

Hospital pain scale

We contemplated a change of perspective.

We helped him sit and
encouraged him to try to cough, but he finally explained that he was afraid
because it was so painful in his chest to cough.

We mentioned that we could
possibly obtain a gastric sample instead of a sputum sample, and the physicians
agreed. They threatened him with insertion of a tube down his throat to
convince him to cough.

This had not been our idea, and we were beginning to
feel uneasy when Adam enthusiastically announced that this child absolutely
must blow bubbles.

We left his bedside as he crumpled in a heap on his bed in
relief that the team was moving on to discuss the next patient.

After rounds,
the local physicians helped Adam find a piece of circular plastic (formerly
used to hang IV fluids) and an old medicine bottled filled with soap.

Our
incentive spirometer was born.

Despite my reservations that an adolescent,
severely ill Haitian boy would muster up the courage to try the bubble-blower,
our patient became suddenly enthusiastic as his face lit up with joy when he
was able to blow bubbles. Despite his fatigue and chest pain, he was able to
produce bubbles for 5 minutes and promised to try once each hour while awake.

The local physicians and patients in the adjoining beds shared our patient's
enthusiasm, and Adam has effectively added creative incentive spirometry to the
treatments available at St. Luc.

As Noel approaches, high-pitched electronic strains of Christmas cheer echo in the courtyards of St. Damien. Strings of tiny multicolored lights are draped across the Virgin Mary and priest statues, posters of jolly Santa visages adorn the halls and the emergency room. A festive Christmas tree has been placed in the glass security/hospitality booth in the foyer of the hospital. Patients are now greeted with inflated purple and white gloves hanging on the boughs among colorful mini-lights and red and gold tinsel garlands. The lab and medical records archive also have trees, and they are focal points for unending staff pictures. While searching for lab results each morning, our interpreters and the lab staff now ask us to pose with them. The mooing of the hemogram machine (the ever-present "cow" in the corner of the lab) is now accompanied by the tree singing high-pitched carols.

Christmas Tree at St. Damien

Hope Pogemiller (MP4) posing with two interpreters from the lab

Hope Pogemiller (MP4) and Abby Montague (PL3) pose with the Director of the Lab

St. Luc also has evidence of the upcoming holidays. There is a team of 5 young men whose job description includes rolling oxygen tanks to bedsides of acutely desaturating patients and wheeling patients to and from the CT scanner and X-ray. One morning, our rounds were followed by evacuation of all the patients out of the emergency department area and into the adjoining ward. The team of young men enthusiastically donned a combination of shower caps, hospital gowns over shorts, and bunny suits (jumpsuits) and filed into the emergency room. They energetically pressure-washed the entire ceiling of forest green plastic tarp lining the tin roof in anticipation of Christmas decorations to come next week. The wall trim has been repainted a matching forest green, and the tiled floors have been scrubbed along with the shelves in each ward.

Pressure washing at St. Luc in preparation for holiday decorations

The temperature has dropped with a persistent wind that stirs the dust and prompts addition of a jacket and socks for breakfast. This chill along with the lights and tunes of the approaching holiday raise everyone's spirits as they plan holiday gift exchanges and fetes. As I walk back to our villa each day, I expect to see piles of bright white snow and am surprised to find piles of light brown rocks, rubble, and light trash dancing in the wind.

We have been enjoying 90+ degree weather and are dreading returning home to the snow and cold. I wanted to share about a recent trip to an orphanage site in Kenscoff.

A little history on Kenscoff: In 1987, Father William Wasson founded Nos Petits Frères et Sœurs (NPFS), French for "Our Little Brothers and Sisters," a home for orphaned and abandoned children in Kenscoff, Haiti.. At its peak, there were over 400 children staying at the orphanage. Currently, there are 318 children at Kenscoff and there are several orphanages run by NPH (Neustros Pequenos Hermanos) in the surrounding communities.

Kenscoff is a favorite of the NPH workers and visitors alike. Set in the scenic mountains, it offers a cool escape from the warm weather of the sea-side.

Kenscoff

Our trip commenced with a 2 hour drive up the mountain side (aided with the use of anti-nausea medications).

Words cannot describe the utter beauty and peacefulness that is Kenscoff. We arrived to find the children engaged in boisterous singing during mass. We made our way to join the festivities, and the children quickly surrounded us. One child was quickly enamored with Hope's sunglasses and also her hair. Calla found herself quickly making friends and conversing with the children in Kreyol. Abby was greeted with a great big hug, which was greatly reciprocated. One child was quite delighted to examine my hands and compare mine to hers.

Chapel at Kenscoff

We were taken on a tour of the facility including the different houses for the children, the kitchen, the volunteer quarters, the clinic, and also the impressive art department.

Clinic at Kenscoff

School at Kenscoff

Mural at Kenscoff

It was great to have the opportunity to engage with the children and experience what others had been saying about Kenscoff.

As the least formal member of our group, this is my favorite greeting. It's equivalent to "what's up, yo" and is best accompanied by some type of hip high five or fist pump. For almost 2 weeks now, we have been enjoying the hospitality of the organization NPH (Nos Petit Freres et Soeurs- Our Little Brothers and Sisters) and learning about the medical system at 2 hospitals in Port au Prince, Haiti. NPH is a non-governmental organization that began in Latin America and has grown to include programs in both countries of Hispaniola (Haiti and Dominican Republic). With a multi-pronged approach, in addition to its pediatric hospital (St. Damien), NPH's programs include orphanages, a free primary school, a rehabilitation center for children and adults, a special needs school, and a pre-school. They provide housing for volunteers and guests, which is adjacent to a cluster of their programs in Port au Prince.

Our chalets have electricity almost continuously, with gloriously cold running water and beds with mosquito nets hanging from the ceiling (sea foam green princess mosquito nets with sequins and beads for the lucky ones). We have fresh rolls baked in an NPH program for breakfast with a steady supply of nutella and peanut butter. We usually have mangos, pineapple, watermelon, and hard-boiled eggs along with our deliciously rich coffee each morning. Some of us converse with the friendly cat who answers to either Obama or Scabio (named for her high fungal and parasite load) prior to the short 10 min walk to St. Luc (hospital for people > 13 years old).

Chalets where we are staying

As Calla mentioned in her latest piece, a few of us have had the opportunity to enjoy daily 7 am rounds at St. Luc, when we walk from bed to bed and the night general doctor (not yet completed residency) rounds with the internal medicine doctor (completed IM residency specialization) and hands off the patients to the day team. We have been impressed with the incidence of chronic disease in proportion to infectious disease. In the inpatient ward, they usually have a section of CVA's next to a section of fever with diarrhea, cough, or nuchal rigidity. Unfortunately high blood pressures in the 240s/140s are not uncommon and are accompanied by hemiplegia along with CT scans with hypo or hyperdensities indicative of ischemic or hemorrhagic strokes. After days of particularly brisk wind and associated dust, we enter the emergency room to see clusters of young patients tripoding with albuterol nebs flowing. We have seen many 16 year old patients with sickle cell or fever with cough as well as the sequelae of home births with absence of prenatal care and hemorrhage or post-partum cardiomyopathy. There is reluctance to seek pre- natal care in part because pre-natal vitamins have been known to encourage larger infants. This raises mortality risk at delivery. St. Luc's collaborates with an infectious disease center across the street, GHESKIO, and patients with a positive HIV or TB test who are stable on room air are transferred to GHESKIO for further evaluation, treatment, education, psychosocial support, and continuity care for these conditions.

After rounds, we walk back to our chalets at Villa Francesca to refill water bottles and enjoy a meal cooked at the NPH-associated restaurant. This bean sauce with hot green peppers over rice with cooked vegetables (ranging from startlingly fuchsia beet potato salad to cabbage and carrots) is undeniably the tastiest lunch imaginable. I can't even begin to describe the mouth- watering, taste-bud tingling, thirst-quenching juice offered each lunch.

The afternoon is filled with discussing patients triaged to the emergency room at St. Luc's with the Haitian doctors and monitoring the evolution of particularly interesting cases from the days prior. We have been broadening differential diagnoses while offering thoughts about patient care. Thorough clinical exams are essential, as patients must pay for IV injections after 24 hrs and pills after 3 days. If a test can be done at St. Luc it is free of charge (headCT, hemogram, bmp) but if the family must bring the sample to an outside lab the family must pay (thoracentesis sample, lipase, thyroid studies). Most of the pleural effusions are not tested, and lumbar punctures are not generally performed as the samples must be analyzed in outside labs.

Today we visited an endoscopy suite, where one Haitian doctor has been trained to do endoscopies to band varices, perform embolizations, and biopsy for h pylori and gastric cancer. These procedures are offered at a greatly reduced price for clinic patients in comparison to private clinics (10 times more).

Endoscopy suite

By 5pm we leave for the day to walk home in pairs and unwind-- each of us in his or her own manner. Calla's callisthenic "movements" are a highlight of many evenings, especially when Adam dons his matching workout uniform. We discuss concerning cases while listening to music, attempting to trick the Wi-Fi into allowing us to send a few emails and connect with home. Dinner is serenaded by Obama/Scabio who demands gifts of food deposits behind the kitchen. She curls up in the bookshelf for the night as we finish dinner and gladly remember we took our malarone in the am.

As Adam so aptly declares, "These bugs, they be immune." During our daily mosquito bite monitoring sessions, Adam has remained firmly in the lead. Our official mosquito magnet, he endorses 98.11% deet spray TID along with his daily malarone.

Each night I am thankful for the particular mix of personalities of my travel companions. Abby's immense heart is available at all moments for discussion of intense emotional moments. Her ultrasound skills are quite valuable. She is also making great progress on development of a sarcastic side. Adam's vast medical knowledge allows him to offer suggestions and broaden differentials. His quick wit provokes laughter frequently--among Haitians and in our travel group. Calla's indefatigable spirit and boundless energy (which she refers to as "being squirrely") lights up the wards. Her word-for-word translations from the inspiring doctor trained in Cuba are invaluable. As Abby proclaimed tonight, "Calla, I just need more of you in my life for some more sunniness."

I'm not really sure how I was so lucky, but these are my travel companions... who I harass freely and frequently (given my innate instigating tendencies). In such a welcoming Haitian community and with the strong emotional support of my companions, I look forward to learning more creole and medicine in the following 2 weeks. One doctor at St.Luc today was laying the groundwork for future collaboration as he announced that after our month we could return to finish our studies, however we would soon return to work in Haiti for 2 yrs or so.

We've settled in pretty well here after our first week. Our Creole is coming along okay - piecing together some of Calla's Spanish and Hope's French with our Haitian friends' phrases. I have been spending my days at St. Damien's Children's hospital with 2 residents from Virginia while Hope and Calla are at St. Luc's for adults (Adam has gone back and forth).

St Luc

Every morning at St. Damien's, we start the day with mass, including small funeral rituals for the dead from both hospitals from the previous day. There's so much more death than I'm used to. As one of our Haitian doctors wrote in the NEJM, "Death's ubiquity, however, does not mean it deserves any less attention or thought" (2012;367:8-9). I have many thoughts, and feel different almost every day. I'm anxious; listening for names of children I know in the Creole list of the dead - not sure if it's the "Jean Pierre" I saw or one of the others. Relieved, when the church banners and cloth are removed and I see the bodies on each stretcher are adult sized. Or grieved when I see the name of the child I was worried about scrawled in blue sharpie across the label on their make-shift burial shroud. On Monday, it was overwhelming with more deceased from over the weekend. Numb on days it's too much to process and still go on working. It's sad when there's few mourners and heartbreaking when you hear the cries of many. Thankfully, I end up feeling peaceful and like we're providing a gentle send-off as we kneel together and hold out our hands with a benediction to the dead. On Sunday, we had a candlelight Vespers service that traditionally has no funerals and renewed our spirits to start the week.

We had our first days off this weekend and took a tour of Port-au-Prince with our driver and one of the day managers where we're staying. They showed us a ruined cathedral, a newly built market, the site of the president's palace, and pointed out their own houses. Signs of the earthquake were everywhere and they pointed out the changes we couldn't appreciate.

Place of worship

Ruins of a cathedral

On Ben and Mahsa's last night, we had a beautiful dinner up on the mountainside overlooking the rest of the city. It took over an hour and a half to get there with traffic but the view was worth it. We were joined by Sister Judy (a nun who has worked in Haiti for years), Dr. Goutier (one of the Haitian staff), and Dr. Goutier's daughter and niece. We spent 3 cool hours eating and chatting about life, medicine, and Haitian history.

View during dinner

Well, dinner's finished. We have to go wash our pans from cooking eggs, tuna and spinach, and heating up ramen (not all at the same time, ew). The local cat, Scabio, has eaten most of the leftovers. The rest of the night we'll shower off the day's sweat and deet, type up our cases, submit our blog posts, and keep in touch with our families.

Hope, Adam, and I have variably spent time at both St. Damien's, the pediatric hospital, and St. Luc's, the adult hospital, and Abby has been at St. Damien's. My favorite part of the day is the morning, when we participate on morning rounds in the observation unit. Pre-rounding is performed by the overnight generalists, who are physicians that have completed their medical school plus their year of social service (a one year requirement in all countries in Latin America, including the Caribbean, as far as I know, prior to either practicing medicine as a generalist, or completing a specialty residency, of which internal medicine and pediatrics are included). Rounds are run by the overseeing internist and include the unit nurse and physical therapist.

Rounds are a linguistic panoply. The charts are in French and rounds waver between French and Haitian Kreyol. With our presence English is added, with interpretation shared between Hope and all of the internists, who speak impeccable English, and Spanish. One of the internists won a scholarship to study medicine in Cuba and who actually feels more comfortable with medical Spanish as opposed to medical French, or so his co-generalists say in jest. I am, as per usual, incredibly inspired by the physicians here. They have chosen this work and receive very little relative compensation and external esteem, but continue to work so hard for the benefit of patients and their families. Rounds shift from discussions of physical exam findings, to pathophysiology, to social realities in which patients live, to how to talk with families when their loved one is dying or has passed away. The physicians frequently talk of competing priorities including the focus on acute care, for example the treatment of infections, and the growing burden of chronic diseases including hypertension, congestive heart failure, type 2 diabetes, and disabilities. In addition, the topic of palliative care comes up frequently, as there are deaths on rounds, deaths in the emergency room, and deaths in the intensive care unit.

In spite of, or perhaps because of, the mishmash of proverbs, dictums, and the like, the universal language of medicine plays strongly. Respiratory distress with a resting oxygen saturation of 75% is sadly not uncommon at all, but spurs specific actions from all involved that readily translate. The same occurs with Kussmaul breathing, and hemiparesis of acute onset. The underlying causes are different, but the human body continues to fail in predictable ways when it is not supported, either by malnutrition or pneumonia or cancer. This universal language is like a not-so-secret code, and being here makes me proud that I am learning to speak the language of medicine more fluently and also awestruck by how much more there is to learn. It has been such a privilege to learn from such wonderful teachers.

615 AM- wake up for the day and get ready, always double checking that I took my malarone. I also double check that my pseudo-fanny pack has the essentials for the day- gloves, hand sanitizer, check that the pulse oximeter has working batteries.

630 AM- meet up with the other residents, Hope, Calla, and Abby, for breakfast, which consists of delicious coffee (Rebo) and a roll with peanut butter.

645 AM- leave for the hospital, a short trek down the road. The compound where we are stay is surrounded by a school. We are typically joined by numerous school children on our walk. Several children arrive by "moto" (motorcycle) and are not wearing helmets. The children are all in uniform and will greet us with "bonjour".

7 AM- arrive at the chapel at St Damien for morning mass lead by Father Rick. Most mornings double as funeral services for patients that have passed away during the last night. Each morning I scan the draped bodies to see if patients I cared for are present.

Chapel window during Mass

8 AM- start rounding on patients in the Urgence area. Patients will stay in the Urgence area until there is room in the hospital or if they are well enough to go home. Typically there are many children with severe malnutrition. I am continually reminded that children who are severely malnourished can also be quite sick from infections including tuberculosis, urinary tract infections, parasitic infections and/or HIV.

Lab tests can take time to track down, with a bit of time going to and from the lab looking for a specific result. I also spend time going to radiology to look at X-rays. We have no radiologist and read all of our films ourselves. There is a CT scanner at the adult hospital that can do either head CTs or whole body CT scans for infants. The CT scanner is broken this week and will be fixed next week by a technician coming from the US.

1030-11 AM- work with a Haitian physician, discussing patients and the possible causes of fever. I pay particular attention to diseases I don't see in the US including typhoid, malaria, and tuberculosis.

1 PM- regroup at the hospital and walk back to our compound for lunch with Hope, Calla, and Abby. Our food is made by the St Luc Foundation at a location across the street called "Francesvillle". At Francesville, they train people for a vocation. There is a pasta factory, welding shop, cement block factory, sewing factory and a restaurant. A typical lunch will consist of rice and beans with a chicken or beef for protein as well as a vegetable or fruit.

Cows on our walk back for lunch

Franceville, a vocational training facility

2 PM-5 PM- return to the hospital and check on patients from the morning. St Damien's recently started a Pediatric Residency and we get to work side by side with the residents in Urgence. It has been great to see them in action. We occasionally process new admissions to Urgence but leave most to the Haitian residents because they want to practice as part of their training program. We assist with pediatric codes and resuscitations as needed.

St Damien

Evening: return home and make dinner. I have ramen most nights, which is quick and easy to make. I spend the rest of the evening looking up different diseases observed during the day and have been reviewing the disease course and complications.